Medicare Update

1. Medicare Update Brian S. Werfel, Esq. Texas Ambulance Association April 12, 2019

2. 2019 Ambulance Inflation Factor

3. 2019 Ambulance Inflation Factor AIF = CPI-U – MFP CPI-U = 2.9% MFP* = 0.6 % 2019 AIF = + 2.3%

5. Impact of MFP on Ambulance Rates

6. 2017 Medicare Payment Data

11. TexasPayment Data

16. Medicare Dialysis Payment Data

24. ESRD Reduction • Section 53108 of the Bipartisan Budget Act of 2018 • Effective October 1, 2018, Medicare payments for BLS non-emergency transports to and from dialysis will be subject to a reduction of 23% off the applicable Medicare allowable • Previously subject to a 10% reduction

25. New Medicare ID Cards

26. SSN Removal Initiative • The Medicare Access and CHIP Reauthorization Act mandated that CMS take steps to remove the social security number from all Medicare ID cards by April 2019 • CMS has started issuing new Medicare ID Cards to beneficiaries starting in April 2018 • New cards replace SSN-based Health Insurance Claim Number (HICN) • New identifier will be the Medicare Beneficiary Identifier (MBI)

27. New Medicare Beneficiaries • CMS stopped issuing SSN-based Medicare ID cards to newly enrolling Medicare beneficiaries in March 2018 • Effective April 2018, all newly enrolling beneficiaries will be issued Medicare ID cards that utilize the MBI

28. MBI Format Where: C –Numeric1thru9 A –Alphabetic Character(A...Z);Excluding(S, L,O, I,B, Z) N –Numeric0thru9 AN –Either Aor N ***NOTE: Alphabeticcharactersare UpperCaseONLY Position 7 – numericvalues 0 thru 9 Position 8 – alphabeticvalues AthruZ (minus S,L, O,I,B,Z) Position 9 – alphabeticvalues AthruZ (minus S,L, O,I,B,Z) Position 10 – numericvalues 0 thru 9 Position 11 – numericvalues 0 thru 9 Position 1 – numericvalues 1 thru 9 Position 2 – alphabeticvaluesAthruZ(minus S, L, O,I, B,Z) Position 3 – alpha-numericvalues 0 thru 9 andAthru Z (minus S,L, O,I,B,Z) Position 4 – numericvalues 0 thru 9 Position 5 – alphabeticvaluesAthruZ(minus S, L, O,I, B,Z) Position 6 – alpha-numericvalues 0 thru 9 andAthru Z (minus S,L, O,I,B,Z)

29. Medicare Beneficiary Identifier CMS wants you to know that there will be no combinations of numbers or strings that could be considered “inappropriate” or “offensive”

30. MBI Generation and Transition Period

31. Transition Period • CMS indicated that the transition period to the new MBI# will run from April 1, 2018 through December 31, 2019 • During this period, claims can be submitted with either the HIC# or the MBI# • Batches can be submitted with claims using either identifier • i.e., you do not have to use the same identifier on each claim in a batch

32. Transition Period • During the transition period, CMS will return on the remittance advice the same beneficiary identifier to you that you submitted on the claim submission • If you submit a HIC#, the remittance advice will return the HIC# • If you submit an MBI#, the remittance advice will return the MBI#

33. Transition Period • Effective October 1, 2018, when a valid HIC# is submitted on a FFS Medicare claim, the remittance advice will be returned with both the HICN and the MBI# • The MBI will be in the same place you currently get information on a “changed HICN” • 835 Loop 2100 • Segment NM1 (Corrected Patient/Insured Name) • Field NM109 (Identification Code)

34. Eligibility Transactions • Effective June 2018, health care providers may look up a beneficiary’s MBI through the MAC-based eligibility portal • Will require the patient’s full name, SSN, and date of birth

35. MBI Utilization • In a March 14, 2019 MLNConnects notice, CMS indicated that, for the week ended March 1, 2019, 67% of Medicare fee-for-service claims were submitted with a valid MBI

36. What Else is New?

37. New SNF Consolidated Billing Edits • On November 2, 2019, CMS issued Transmittal 2176 • Implemented a new set of Common Working File (CWF) edits to identify ambulance transports that should be bundled to the skilled nursing facility under the SNF Consolidated Billing Regime • Edits took effect April 1, 2019

39. OIG Report Methodology • OIG reviewed $25.3 million in Medicare Part B payments to ambulance suppliers for beneficiaries that were in a Part A SNF stay between July 1, 2014 and June 30, 2016 • 58,006 “beneficiary days” that included at least one claim line for ambulance transportation • 100 beneficiary days selected for review sample • Sampled beneficiary days were reviewed to determine whether the HCPCS or CPT codes on the associated hospital outpatient claim indicated that the hospital outpatient service was bundled to the SNF

40. Key Finding The OIG determined that 78 of the 100 beneficiary days they sampled contained a Medicare overpayment, because the ambulance supplier transported the beneficiary to receive services that did not suspend or end their SNF resident status and which were not related to maintenance dialysis

41. OIG’s Recommendation “We recommend that CMS redesign the CWF edits to prevent Part B overpayments to ambulance suppliers for transportation services provided to beneficiaries in Part A SNF stays.”

42. New Edit Mechanics • Effective April 1, 2019, ambulance claims for beneficiaries within a Part A SNF stay will be deniedto the extent they are: • Submitted prior to the submission of the associated hospital claim; or • Submitted after the submission of the associated hospital claim, unless the hospital claim contains at least one HCPCS or CPT code on the list of excluded codes

43. CMS Clarification “The instruction in business requirement 10955.5 is intended modify CWF IUR 7275 to identify previously rejected/denied ambulance claims upon receipt of an outpatient hospital claim containing an excluded service and to remind MACs and SSMs that claims returned for CWF IUR 7275 should continue to be systematically adjusted by the SSMs as they are today.  Therefore, no action should be required for ambulance suppliers to reprocess their claims once the hospital claim containing the excluded service is received.”

45. CMS PCS Template • On July 20, 2018, CMS released a template PCS form • CMS indicated that the template was designed to assist physician’s, non-physician practitioners (NPP), licensed social workers, case managers, and discharge planners in completing the PCS for repetitive, scheduled non-emergency ambulance transportation • Use of this template is voluntary

46. CMS PCS Template

47. CMS PCS Template

49. Medicare Appeals Process

50. ALJ Average Processing Times